Which role for chest x-ray score in predicting the outcome in COVID-19 pneumonia?

Abstract

Objective We aim to demonstrate that a chest X-ray (CXR) scoring system for COVID-19 patients correlates with patient outcome and has a prognostic value. Methods This retrospective study included CXRs of COVID-19 patients that reported the Brixia score, a semi-quantitative scoring system rating lung involvement from 0 to 18. The highest (H) and lowest (L) values were registered along with scores on admission (A) and end of hospitalization (E). The Brixia score was correlated with the outcome (death or discharge). Results A total of 953 patients met inclusion criteria. In total, 677/953 were discharged and 276/953 died during hospitalization. A total of 524/953 had one CXR and 429/953 had more than one CXR. H-score was significantly higher in deceased (median, 12; IQR 9–14) compared to that in discharged patients (median, 8; IQR 5–11) (p < 0.0001). In 429/953 patients with multiple CXR, A-score, L-score, and E-score were higher in deceased than in discharged patients (A-score 9 vs 8; p = 0.039; L-score 7 vs 5; p < 0.0003; E-score 12 vs 7; p < 0.0001). In the entire cohort, logistic regression showed a significant predictive value for age (p < 0.0001, OR 1.13), H-score (p < 0.0001, OR 1.25), and gender (p = 0.01, male OR 1.67). AUC was 0.863. In patients with ≥ 2 CXR, A-, L-, and E-scores correlated significantly with the outcome. Cox proportional hazards regression indicated age (p < 0.0001, HR 4.17), H-score (< 9, HR 0.36, p = 0.0012), and worsening of H-score vs A score > 3 (HR 1.57, p = 0.0227) as associated with worse outcome. Conclusions The Brixia score correlates strongly with disease severity and outcome; it may support the clinical decision-making, particularly in patients with moderate-to-severe signs and symptoms. The Brixia score should be incorporated in a prognostic model, which would be desirable, particularly in resource-constraint scenarios. Key Points • To demonstrate the importance of the Brixia score in assessing and monitoring COVID-19 lung involvement. • The Brixia score strongly correlates with patient outcome and can be easily implemented in the routine reporting of CXR.

Chest Radiograph Scoring Alone or Combined with Other Risk Scores for Predicting Outcomes in COVID-19

“…There has been recent interest in the potential of scoring radiographic severity of SARS-CoV-2 pneumonitis changes to predict important patient outcomes. A number of studies report such data [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. Our study focusses on percentage opacification, a simple and readily applicable scoring system, comparing it directly to BRIXIA and RALE scores that have been studied more extensively.…”

“…Two other studies have also examined the impact of radiological severity scoring systems in predicting patient outcome. Maroldi et al [12] examined the BRIXIA score in a cohort of similar size. That study incorporated radiographic scoring for I n p r e s s radiographs taken during the patients' SARS-CoV-2 admission to determine if the BRIXIA score could predict outcomes.…”

“…Chest radiography has been shown to have limited sensitivity and specificity for identification of patients with SARS-CoV-2 [3] but can help in identifying patients with the disease [3][4][5]. Also, a number of studies have demonstrated that the severity of lung involvement on chest radiography in SARS-CoV-2 is closely correlated with a number of key outcomes for patients including intensive care unit (ICU) admission and death [6][7][8][9][10][11][12][13][14][15][16][17][18][19][20]. A number of scoring systems have been described in the literature for assessing the severity of lung involvement in SARS-CoV-2.…”

“…A number of scoring systems have been described in the literature for assessing the severity of lung involvement in SARS-CoV-2. The most widely employed and studied systems include Brixia[ 7 , 12 , 21 ] and radiographic assessment of lung oedema (RALE/modified RALE)[ 6 , 13 , 14 , 16 , 22 ]. A large study has not yet been performed comparing all three of BRIXIA, RALE and percentage opacification.…”

New Scoring System for Predicting Mortality in Patients with COVID-19

“… 23 A worsening Brixia score and a Brixia score of >3 on admission are correlated with disease severity and death. 24 Feng, et al 25 found that age, neutrophil-lymphocyte ratio, and chest computed tomography severity score corresponded with severe pneumonia in COVID-19, and developed a nomogram on the risk of severe pneumonia. Given its predictor of severity and mortality, chest X-rays were nonspecific, but low in cost and easy available.…”